Faculty Perspectives: Concerns about the new prescription drug deal
We commend the U-M administration for establishing in Jan. 2003 the University Privacy Oversight Committee, a University-wide committee to advise the president and provost about issues that may affect the privacy of U-M students, faculty and staff. The need for this committee was articulated by the Civil Liberties Board of the Senate Assembly more than two years ago, and it is excellent that it is now being implemented.
This respect for privacy is further displayed by University Standard Practice Guide Section 601.14: "It is the policy of the University of Michigan that the use of Social Security numbers as common identifiers and the key to databases be discontinued, except where required for employment and a limited number of other business transactions. The expectation is that there will be a steady and purposeful movement away from dependency on Social Security numbers, and that the regulations of this policy will be fully implemented no later than the year 2002."
We could only be dismayed, therefore, by the use of Social Security numbers (SSNs) as the identifier for all University members and dependents in the new Pharmacy Benefits plan implemented in 2003. This, despite the direct reply from the selected Pharmacy Benefits Manager (PBM) to U-M's Request for Proposals: (Question) "L-2. We will provide you a unique personal identifier (UMID) (not SSN's) that are [sic] 8 characters. Will you be able to accommodate this requirement?" (Answer): "Yes."
Privacy concerns go much deeper. The form that must be submitted to AdvanceRx.com in order to receive drugs by mail solicits private and personal medical histories and asserts: "By returning this form to http://AdvanceRx.com , you consent to the use and release of your health information and that of your covered dependents (if you are their guardian or authorized representative) to your health plans and health care providers/agents for health benefits management." Who gets this information and for what end?
Due to a media storm over the use of SSNs and quick action by the Senate Advisory Committee on University Affairs (SACUA), the Benefits Office has offered faculty, staff and retirees the option to obtain alternative ID cards ("How to obtain an AdvancePCS alternate number ID card," The University Record, Feb. 3 2003, page 2). The office instructs people to "cut up old cards into multiple pieces and deposit the pieces in different trash bins" in a heroic effort to thwart identity theft.
SACUA Chair Charles Koopmann has been a leading proponent of privacy safeguards. In recent communications to elected faculty and PBM oversight managers, he pointed out that, "Since we must carry these cards with us the #s on them should not be remotely close to our SSNs nor should the SSNs be easily accessed using these our health identity #s. By this use, all patients have been needlessly exposed to identity-theft." In fact, the U.S. Federal Trade Commission's (FTC) latest figures show that identity fraud tops the list of complaints received by the FTC (42 percent in 2001). According to FTC official Bob Medine, "The Social Security number is the one piece of information that most facilitates identity theft, as it opens the door to an individual's financial lifeproviding access to checking accounts, savings accounts, brokerage accounts, etc."
We at the American Association of University Professors (AAUP) believe the U-M administration should withdraw the tens of thousands of SSNs that it sent to the PBM, abolish use of the SSN as the default identifier and apologize to the U-M community for violating its own published policy.
These privacy concerns were triggered by actions taken by the Benefits Office starting in 2003 to change our prescription drug coverage programs, putting them in the hands of a single vendor that has agreed to share its information with University officials. Previously, pharmacy benefits were handled within separate health care plans selected by individuals. That element of choice has been removed and a PBM, AdvancePCS, was selected.
Despite stating as long ago as May 2002 that "the arrangement is contingent upon the successful completion of a contract between AdvancePCS and the University of Michigan," the University allowed AdvancePCS to take over administering our pharmacy benefits without a contract, thereby providing access to health and other information about thousands of employees, retirees and their families. The U-M official overseeing development of the contract told us that Staff Benefits is acting on "good faith" that Advance and the University will complete a contract, based on Advance's status as the accepted bidder for the business.
There is, however, no specific promise about when a contract might be forged.
Who is accountable for protecting patients' health or privacy when no contract exists? How can a public university spend millions, including payroll contributions provided by employees themselves in many cases, without contractual safeguards? We have been told that the University administration routinely employs contractors prior to the contracts being signed, and maybe it is legal to do so. But is it always wise?
Keith Bruhnsen, at point for Staff Benefits on the PBM issues, admits there are major areas of disagreement still looming before a contract can be signed. Several of those areas are crucial to Advance's proposal, namely programs involving Advance's plans to contact physicians and pharmacists to recommend switching patient medicines, a new appeals process sought by U-M and an arrangement under which the University administration is paid back money by Advance based on rebates the PBM gets from drug companies in exchange for giving their products more market share.
The administration of the drug benefit program already has stumbled, by using SSNs as identifying numbers for the prescription drug program without people's permission or knowledge. And consider, for example:
• AARP and its health insurance companyon allegations of misconduct, deceptive business practices and seeking unjust enrichmentsued AdvancePCS in federal court.
• Advance and other PBMs are under investigation by federal officials interested to know what deals Advance and the others are making with pharmaceutical companies in return for steering millions of Americans to certain prescription drugs, and not others, according to news reports.
• Advance won the business from U-M even though it refused in its proposal to turn over crucial pricing information requested for the bid. Other bidders offered to do so, or provided part of it in their proposals.
The U.S Department of Health and Human Services is in the process of promulgating new guidelines that call into question many of the incentives offered by drug companies and PBMs to doctors and pharmacists to switch patients from one drug to another, suggesting some such incentives are tantamount to kickbacks and other illegal behavior.
Will Advance's practices pass muster? It's hard to know, since there is no contract to analyze. It is also unclear whether what Advance and U-M agree upon will be consistent with federal guidelines due out in the spring.
Despite this fog of uncertain arrangements and unknown accountability, it is good to learn that some people are working hard to resolve problems in the patients' favor. Recently a faculty member experienced difficulty obtaining essential medications by mail order from Advance, and he brought his case to Koopmann (koopmann @med.umich.edu). Acting swiftly and effectively with the Benefits Office, the SACUA chair was able to effect a satisfactory solution. This may be an effective channel for documenting and resolving additional problems. Prof. Koopmann assured the Senate Assembly at its Jan. 27 meeting that the Benefits Office is aware of the problems and that corrections will be made for 2004.
Why must faculty and staff remain exposed for so long? Corrective measures ought to be immediate.
The Senate Assembly already has anticipated the need to give the faculty an opportunity to provide feedback about their experiences and concerns about their new adventure in drug benefits. The entire faculty will be polled this summer regarding their satisfaction with the arrangements. Is this really the money-saver the U-M administration is looking for? Is it worth the cost to your patient privacy?
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